Timeline of Events
CervicalCheck is established in Ireland to provide free smear testing for women aged 25-60 as a ‘quality-assured, organised and population-based screening programme’.
Vicky Phelan has a smear sample collected following the birth of her son. Her test is read as clear or no abnormalities detected. She is advised to return for repeat testing in three years.
The first case of cervical cancer detected through the screening programme is referred back for review. This internal audit process will undergo many revisions over the coming years.
Vicky requests an early smear test due to concerning symptoms she’s begun experiencing. She is subsequently diagnosed with advanced cervical cancer.
Vicky’s diagnosis of cervical cancer prompts her inclusion in an audit being conducted by CervicalCheck during this time. Her 2011 smear test is reviewed and found to be inaccurate, resulting in a delay in diagnosis and treatment. At this time, audit results were not published or communicated to consultants.
August 2015 – early 2016
Over the course of several meetings, CervicalCheck decides treating clinicians should be notified of audit results as a result of the HSE’s new work on the national disclosure policy.
Letters are issued to treating clinicians over the course of many months, advising them to add the audit results to the patient’s medical record and to ‘use their judgement’ when deciding to disclose this information to the patient.
Some clinicians argue with CervicalCheck over whose responsibility it is to tell patients of their audit results. Only a fraction of the total number of women affected are informed of their audit results during this time.
Vicky has a chance reading of her medical record while waiting for an appointment. She sees her smear audit results for the first time and realizes her diagnosis in 2014 had been delayed due to her inaccurate smear reading in 2011.
Sadly, Vicky is diagnosed with a recurrence of her cervical cancer and told she is terminally ill. She realizes her prognosis could likely have been different if her smear test in 2011 had been accurately read and she had received earlier intervention.
Vicky brings a high court case against the HSE and Quest Laboratories claiming medical negligence and breach of duty in failing to inform her of her audit results.
Vicky settles her case against Quest Laboratories for €2.5 million but refuses to sign a non-disclosure agreement. Her case then becomes public knowledge and draws national attention and outrage. Despite her experience, she continues to urge women to undergo cervical screening, recognizing their overall importance in reducing cervical cancer deaths.
Health Minister, Simon Harris promises to write to consultants to ensure all 221 women and next of kin affected are told of their audit results.
Dr Gabrielle Scally, a distinguished public health doctor from the UK, is appointed by the HSE to conduct a Scoping Inquiry into the issues surrounding the CervicalCheck debacle.
The Minister also announces an independent expert review panel has been commissioned with the Royal College of Obstetricians and Gynaecologists in the UK to review the smear history of women who participated in CervicalCheck and later developed cervical cancer.
The Minister establishes a CervicalCheck Steering Committee to provide oversight and assurance on the key implementation actions the Government takes in relation to the CervicalCheck programme. Patient representatives Lorraine Walsh and Stephen Teap are appointed to the committee.
Vicky Phelan, Lorraine Walsh and Stephen Teap approach the Irish Cancer Society, the Marie Keating Foundation, and the Irish Patients Association to establish a support group for the women and families affected by the CervicalCheck failures.
After several months of investigation, the Scoping Inquiry into the CervicalCheck Screening Programme is published by Dr Gabrielle Scally. He reports CervicalCheck ‘was doomed to fail’ and the problems uncovered are indicative of a ‘whole-system failure’.
221+ Patient Support Group holds its first private quarterly member meeting in Athlone to provide information, advice, and support in a structured and confidential manner to those affected.
The RCOG Independent Review is completed.
The 221+ Patient Support acknowledges their readiness to support the additional women and next of kin identified through this review.